Investing in midwifery education and the maternal health workforce, extending Medicaid benefits, and disaggregating data are key to reducing maternal mortality disparities, said public health experts, educators, and advocates during a House Committee on Appropriations subcommittee hearing on Tuesday.
Subcommittee Chair Rosa DeLauro (D-Conn.), in her opening remarks, noted that women in the U.S. today are more likely to die during childbirth than were their own mothers.
“This is unacceptable … It’s a national disgrace,” she said.
Roughly 700 women die from pregnancy-related complications each year, DeLauro said, citing CDC data. She noted that death rates differ dramatically by race.
The U.S. maternal mortality rate is double that of other industrialized nations, and greater than Kazakhstan and Kuwait, which, DeLauro said, begs an important question: “Are we really a nation that values the lives of mothers?”
Black, American Indian, and Alaska Native women are two to three times as likely to die from pregnancy-related causes as white women. These disparities remain even when income, education, and access to care are taken into account, she noted.
Stacey Stewart, president and CEO of the March of Dimes, an advocacy organization for mothers and babies, echoed DeLauro’s concerns.
“Still, in the U.S., two babies die every single hour and two women die from pregnancy complications every single day,” she said, despite the fact that preterm birth rates have been decreasing in the last few years.
Expanding Midwifery Care
In exploring what separates the U.S. from other countries with better health outcomes, Wendy Gordon, DM, MPH, associate professor and chair of the department of midwifery at Bastyr University, near Seattle, noted that the U.S. maternity care system offers an approach that’s both “too little, too late” and “too much, too soon.”
On the one hand, underserved individuals can’t access the care they need, and on the other, people who are healthy avail themselves of interventions they don’t need.
What midwifery care does, she said, is locate that “sweet spot” by providing only the interventions that are needed, in a timely way, thus avoiding the risk of negative outcomes that happen at either end of the care spectrum.
However, midwives are “severely underutilized” in maternity care and present during only 10% of births, Gordon noted.
By contrast, in other “high-resource” countries with better maternal health outcomes — such as England, the Netherlands, Australia, and New Zealand — midwives are the main providers, while obstetricians specialize in high-risk pregnancies, she said.
Because there aren’t “dedicated federal streams of funding” the way there are for nurses and physicians, it’s hard to even become a midwife, Gordon added.
Her own midwifery education program came about through a grant from the Health Resources & Services Administration (HRSA) scholarships for disadvantaged students, which was earmarked for midwifery in 2020.
Gordon urged lawmakers to pass the Midwives for MOMS Act, which would help to grow the midwifery work force by providing funding to expand existing programs, creating new midwifery schools, providing direct support for students, and increasing the number of clinical preceptors.
She also pressed Congress to pass the Black Maternal Health “Momnibus” Act, a set of a dozen bills that look to improve maternal healthcare for Black women and other women of color by expanding and diversifying the workforce, improving data collection, and supporting payment reform, among other measures.
When asked by the subcommittee’s ranking member, Tom Cole (R-Okla.) what specific interventions could help to eliminate the disparities in outcomes by race and geography, Stewart noted that many Southern and Midwestern states — including Cole’s home state — have some of the worst outcomes in preterm birth rates.
One of the most effective interventions to eliminate these poor outcomes is to ensure that women have access to affordable quality healthcare “before, during, and after pregnancy.”
Stewart called for extending Medicaid for at least 1 year postpartum. While the American Rescue Plan Act extends Medicaid from 2 months after birth to 12 months, those changes are optional and should be “mandatory for all women,” Stewart said.
Carol Sakala, PhD, MSPH, director for maternal health at the National Partnership for Women & Families, responded to Cole simply: “We have a data problem.” Without being able to compare how women fare relative to an average, it’s impossible to tackle any disparities, she said.
Sakala called for “better and more consistent data disaggregation” by race, ethnicity, and other demographic factors.
And in terms of particular areas of research, Sakala highlighted community-led perinatal worker groups, which she characterized as a “promising” new model that merits more study. These groups provide women who often experience discrimination in healthcare with dignity and respect, and many incorporate midwifery and doula services — nonclinical workers who support mothers physically and emotionally through their pregnancy.
“This model could play a major role in mitigating our maternal health crisis,” Sakala suggested, urging its evaluation.
Additionally, she underscored the importance of having paid family and medical leave, which allows women “to attend to and recover from” pregnancy-related conditions and supports “healthy family formation.”
Sakala noted that just having insurance isn’t enough when women have to choose between missing work and attending an appointment. Only 21% of workers in the U.S. have access to paid leave from their employers, she said.
Notably, the children of mothers with paid leave are more likely to be breastfed, have medical check-ups, and receive regular immunizations.
She pressed the subcommittee to pass the Family Act, which supports paid family and medical leave, as well as the Healthy Families Act, which ensures families can access paid sick days — requiring employers to grant 1 hour sick leave for every 30 hours worked.
Maternal Mental Health
Finally, several subcommittee members asked witnesses about improving maternal mental health, which, because of stigma, often continues to go untreated.
DeLauro noted that suicide and overdose are a leading cause of death within the first year after giving birth.
Lisa Asare, MPH, assistant commissioner for the division of family health services at the New Jersey Department of Health, agreed that there was a maternal mental health crisis even before COVID, but it has been exacerbated because of isolation.
Asare said that her department is looking to train doulas and community health workers in peer support. While not licensed mental health practitioners, they can identify women who need to be referred to professional care, she said.
Stewart said that group prenatal care, which is another form of effective peer support, can be extended into the postpartum period. She also advocated for more funding for the Maternal Mental Health Hotline, which the subcommittee helped to finance in fiscal year 2021. The hotline helps to screen women before and after pregnancy for mental health problems and connects them to needed support.